Recapping RSNA(i)18

Key Takeaways

  • Fear of AI has given way to exuberant optimism/anticipation/impatience.
  • Many vendors are trying to pivot their legacy products as next-generation AI platforms/marketplaces.
  • Confidence in AI performance will only come with independent validation.
  • Cloud has faded to the background.
  • Not everything about AI is good news, adversarial attacks could bring about a new era in cyber-security concerns for providers.

Over the course of the last 18 months artificial intelligence (AI) has matured to the point where there are several viable vendor options for nearly every use case.

AI dominated every aspect of the annual gathering of the Radiological Society of North America (RSNA18) in Chicago. Self-described ‘machine learning’ vendors with a presence on the conference floor more than doubled from 49 in 2017 to over 100 in 2018, 25 of which were first-time presenters.

I moderated a panel hosted by Life Image on practical uses cases of imaging AI and was blown away by the conversation that ensued, particularly what I learned about how the veteran radiologists feel about being “replaced.” During the question period, a senior radiologist approached the microphone to address a comment made by a more junior radiologist on the panel which he interpreted to be too pessimistic about the potential for AI. To paraphrase the elder, “Listen here sonny, you are too young to fully appreciate what you don’t know, and you don’t know how many mistakes you are truly making on a day to day basis. 1-2 percent error rate due to fatigue alone. WE NEED AI to save us from ourselves.”

Not all old school radiologists are so optimistic: “When you’re going up the ride, you get excited,” noted University of Chicago radiologist Paul Chang said during his workshop on AI. “But then right at the top, before you are about to go down, you have that moment of clarity—‘What am I getting myself into?’—and that’s where we are now. We are upon that crest of magical hype and we are about to get the trench of disillusionment… It is worth the rollercoaster of hype. But I’m here to tell you that it’s going to take longer than you think.”

The cloud fades to the background

Last year, the major cloud vendors each had a significant footprint at RSNA, but this year the two largest, Amazon and Microsoft, were nowhere to be found. Only Google Cloud had a significant, if smaller than last year’s, presence. Donny Cheung, one of the Google Cloud team leaders, was on the panel I moderated and his message to the imaging community could be boiled down to two words: storage and compute. No dashboards or toolkits or tensorflowing, just storage and compute, a smart and refreshing strategy amidst the obvious feature creep many other vendors suffer from.

Over the course of the last 18 months artificial intelligence has matured to the point where there are several viable vendor options for nearly every use case.

What’s Facebook doing here??

While it was surprising that Amazon had no noticeable presence, it was even more surprising to find Facebook making news on the conference floor. Facebook AI Research (FAIR) has partnered with the Center for Advanced Imaging Innovation and Research (CAI2R) in the Department of Radiology at NYU School of Medicine and NYU Langone Health to release the fastMRI, an open source dataset for training and testing machine learning algorithms to reconstruct MRI images.

This offering is roughly equivalent to similar X-Ray and CT datasets released by NIH. Given that algorithms ALWAYS significantly outperform on all metrics against the data used to train them versus new data, the industry needs independent validation of AI claims so it is unlikely that Facebook moves the needle with this offering.

Platforms abound

PACS vendors want to get in on the AI action by positioning their existing products as AI marketplaces or platforms (Philips HealthSuite Insights, PureWeb, LifeImage, GE Edison, FujiFilm REiLI, Nuance AI Marketplace, Blackford Analysis). Nuance has shown there is a viable market for these platforms, counting 40 startups and health systems among user groups for its marketplace. There is no shortage of startups taking this approach (MDW,, Medimsight, Lify, Fovia). Imaging hardware vendors refused to be left out too, with many partnering with AI vendors to embed their algorithms on the “edge.”

AI is global

International AI startups, particularly from Israel, China, and South Korea, stood out from the crowd in terms of their approach to product design, but only the companies from Israel have been able to break into the US market so far. One Korean company voiced frustration with the FDA, saying it couldn’t understand what was wrong with their application. I wonder if it underestimates the importance of using data from US patients to validate their algorithms?

Some cautionary tales were told…

Not everything we learned about AI at RSNA was positive. A paper presented at the conference showed that neural networks could be used to insert malignant features into mammograms giving a false positives, and then reverse the alterations without detection. Even scarier, it took about 680 images to train the algorithm that executed the adversarial attack. Cyberattacks have been increasing in healthcare over the last couple years, but mostly just for taking data hostage and demanding ransom to get it unencrypted. This type of attack would represent a frightening new paradigm in cyber-vulnerability, and it is certainly not difficult to imagine ways this could be exploited to make money. It could be used for a different sort of ransom, with every image appearing to show cancer until a ransom is paid and the adversarial attack is reversed. Another conceivable way this type of attack could be exploited would be falsifying data for clinical trials.

Stay up to the minute.

Did You Know?

Connected Health Conference: Digital Health’s Opportunity to Capture a Positive View of Aging

The Connected Health Conference and its predecessor events, the Partners HealthCare’s Connected Health Symposium and the Personal Connected Health Alliance’s Connected Health Conference (a HIMSS event), aim to frame digital health advancements in the context of improving clinical care delivery as well as personal engagement.

It’s “personal” engagement because the conference recognizes that “patient” engagement only occurs in a healthcare setting. Improving health and well-being must be part of our everyday lives – or, as this year’s conference theme put it, part of “the connected life journey.”

In particular, this year’s Connected Health Conference examined digital health’s impact on getting older – a process that speakers such as AARP CMO Dr. Charlotte Yeh attempted to destigmatize by emphasizing the positive aspects of aging, including learning and building social connections. Get it right, Yeh said, and aging makes us happier – and happiness has been linked to better health and longevity.

With that in mind, here’s a recap of various digital health solutions discussed at the conference, along with Chilmark Research’s assessment of the maturity of these solutions.

Condition management: Almost mature. Multiple speakers highlighted the potential of chronic condition management solutions to provide targeted engagements and interventions, especially those that draw upon principles of behavioral science as opposed to marketing. Plus, Livongo Health announced a partnership with Alaska’s Medical Park Family Care that is notable because providers approached the vendor, with both stakeholders then approaching the payer together; this could be a sign of a shift, as payers or large employers typically initiate the conversation (and may not even get providers involved at all). If there’s a caveat, it’s solution sprawl; Dr. Adrienne Boissy of the Cleveland Clinic noted that the hospital has 27 different apps for engaging with patients; that number has to go down.

Providers don’t want artificial intelligence but, rather, the output of AI – clinical decision support, diagnostics, more personally tailored care plans, 30-day readmission risk scores, and so on – but that hasn’t stopped vendors from promoting the use of AI and machine learning.

Telehealth: Getting there. As Carla Kriwet of Philips noted, the holdup for telehealth adoption is not the maturity of the technology; it’s the clinical culture that still emphasizes in-person visits and the related struggle to define telehealth’s value-add. (Kriwet didn’t mention the regulatory and reimbursement challenges, which Twitter users in the audience were quick to point out). Plus, telehealth requires broadband access, which millions of Americans still lack. That said, physicians are a bit more bullish on telehealth and other technologies at the point of care, AMA President Dr. David Barbe said, pointing to AMA survey data he shared on stage at the Connected Health Conference.

Decision support: Getting there, slowly. Providers don’t want artificial intelligence but, rather, the output of AI – clinical decision support, diagnostics, more personally tailored care plans, 30-day readmission risk scores, and so on – but that hasn’t stopped vendors from promoting the use of AI and machine learning. The baseline ongoing challenge, of course, is bringing disparate data sets together to let AI algorithms do their thing, and then deploying them at the point of care in a timely manner, which is no small task when those data sets include months-old claims and years-old HHS reports. Oh, and don’t forget data streams from remote patient monitoring devices. Smart vendors and providers are using an API approach to address this data deluge, but progress has been slow.

Chat bots: Getting there, slowly. Conversations with bots allow engagement solutions to scale, especially for low-acuity care as well as general wellness and mood. But for every Conversa Health (where chat bot responses come from a database that also identifies whether a particular response must automatically trigger an escalation to higher-acuity care), there’s an Ada Health (where users must escalate on their own, for a $25 fee). Here, the market has yet to separate the wheat from the chaff, as is evidenced by Ada Health’s latest $47 million funding round.

Blockchain: Emerging. There is certainly potential for blockchain to provide secure data sharing, and use cases are beginning to pop up. Hashed Health is addressing provider licensure in the state of Illinois, which will help the state store up-to-date credentialing information and share it with payers; the hope is to eliminate the bottlenecks in an often-manual process. Meanwhile, MintHealth, promises a personal health record platform powered by blockchain. The presence of a unique global identifier, which blockchain enables, could let patients manage their records better than previous PHRs; plus, MintHealth plans to sell to commercial payers, who have clear financial incentives to better engage members. Even if these efforts fall flat – and, let’s face it, PHRs have a poor track record by placing too much burden on the patient – they have at least demonstrated practical examples of blockchain in healthcare.

Virtual reality: Incubating. Qualcomm and ForwardXP announced a VR simulation at the Connected Health Conference that lets users experience stroke symptoms, in an effort to help them better identify warning signs. While this could be an effective educational tool for medical professionals, we’re not sold on its viability for consumers, who would either need to use it on their own VR devices or travel to an educational session somewhere with a VR device. In one session, Dr. Brennan Spiegel of Cedars-Sinai Health System cautioned against “overpromising and under-delivering” with VR. Pain management is an effective clinical use case; giving patients the 21st century equivalent of a ViewFinder probably isn’t.

Wearables: Incubating (still). Wearables provide data such as steps taken, exercises completed, hours of sleep, but they don’t yet provide insight – and that hasn’t changed since I wrote about it for way back in 2014. One reason is the separation between wearable information and clinical workflows, which hampers the ability of wearable data to reliably contribute to decision support. Another is the accuracy of the data; we still earn “steps” for folding laundry or doing dishes, but not for riding a bicycle, so physicians can’t be blamed for viewing wearable data with a dose of skepticism. Finally, for all their talk, consumer device makers such as Apple, Fitbit, Google, and Samsung have yet to crack the chronic condition management market – only Nokia has, and its market share lags substantially.

The smart home: Not even close. Speakers mentioned a number of futuristic use cases, ranging from home-based robot caregivers to fall alert sensors tied to home security systems to sensors that monitor water usage, detect abnormalities, and alert caregivers of potential problems. No one mentioned which healthcare stakeholders would subsidize the high cost of this technology, train end users (including caregivers), or monitor data and escalate a case as needed. Nor did anyone mention the ROI for such technology deployments, or the impact on clinical outcomes.

Closing Thought

Ultimately, the goal of these solutions is to meet the needs of people managing their health, whether on their own or through the clinical experience. As such, these solutions need to ease their way into clinical workflows and everyday life and prove their potential to play a part in the connected life/care journey. Until then, they will simply remain stuck in the technology hype cycle.

Cerner Impressions – Value Based Solutions: Payer/Provider Markets Getting Ever Blurrier

fishyangWe all know that two of the principle new competencies for providers in the value based market is: 1. population health management and, 2. consumer engagement. Long the purview of the health plan market business and technology sector, one of the burning market questions is how the at-risk provider market will acquire these competencies.

Health plans and related health plan technology vendors have positioned both technologies and services for the at-risk market – and much of the market discussion earlier this year focused on health plan and health plan technology vendor market opportunities.

However, after attending Cerner’s population health management conference last week, it is worth re-emphasizing some very notable investments and successes in population health among the provider vendor community. Cerner’s strategy supports much of the population health business requirements of a provider organization including: risk identification, program enrollment, tracking, patient outreach, milestone and outcomes tracking and reporting.

Both vendor and attendee (providers, employers and some heath plans) conversations aligned with a model that shifts from a patient to a consumer focus and squarely placed the consumer (not the patient) at the center. Next up are social, financial and additional lifestyle metrics that make up the 70-80% of health status beyond direct clinical interventions.

Payers out there… Sound familiar?

As Cerner and others roll out these capabilities, it would be a sound payer strategy to take a look. Here’s why.

The provider solutions already have the clinical information and capabilities that have long been sought after by payers. As 10 years of as yet incomplete efforts among most of the payer care/population health management vendors would suggest, adding claims data to a strong clinical solution is easier than adding clinical information to a payer claims based solution.

And, it is of course the clinical information, combined with the claims/transaction data, that renders information useful in support of a population health management strategy.

Case in Point
Twice now I have been contacted by my health plan regarding prescription compliance. In the first case, I was encouraged to renew and continue taking a prescription that had been discontinued because of a potentially life threatening allergic reaction. In the second case, I was encouraged again to renew a prescription that had been discontinued because I no longer needed it. When I contacted the health plan representative, he admitted that they only used claims data and had no insight into any related clinical information. I asked to be taken off any further communications.

At the center of any population health initiative is the need for effective provider or consumer engagement, which requires credible, accurate, complete and timely information delivered at point of decision. Without that, both providers and consumers rapidly lose confidence and the ability to effect outcomes and improve health status is compromised

Health plans have used health plan care management vendors for years for their population management – TriZetto, ZeOmega, etc. Many health plans are looking at ways to leverage their traditional population health solutions to the ACO market. Cerner will ultimately compete directly with the traditional health plan population health/care management solutions. Cerner – and their competitors – have an advantage in that their solutions already integrate and use clinical information, something the payer care management/population health market is still trying to execute on.

Cerner, and others in the provider space, are more rapidly addressing this more robust clinical/claims information environment. Solutions are rapidly blurring across payer and provider care management/population health management solution domains,

While there is work to be done on all sides, health plans, particularly those pursuing joint venture strategies, should look carefully at solutions emerging from the largely unfamiliar provider market. Careful assessment, however, is required. Also expect further market consolidation via merger and acquisition (e.g. Evolent-Valence Health, Wellcentive-Philips, Phytel-IBM, etc.) among payer and provider vendor solutions.


Home Is Where the Health Is: The Current State of Connected Health

Digital Reality

2014 has served as a coming out party for all things Connected Health. The buzz around telemedicine, virtual visits, and device-based monitoring solutions is rising to a fever pitch. For clinically oriented healthcare stakeholders, this has been a welcome shift away from the noise around wearables and the limitations of patient portals.

Skeptics may comment that we’ve heard this song before, but even they should take heed that the traditional barriers to telemedicine – reimbursement and need for better proof of outcomes/ROI – are steadily diminishing. The million (or billion) dollar question remains – is the market ready to start buying into these advanced tools and models of care?

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Consumer Health Data Plays: Vision? Yes. Value? Maybe…

Challenges & Opportunity

In an otherwise slow summer, health IT got caught up in a whirl of excitement last month when Apple, Samsung, Google, and a few smaller players announced their own forays into the digital consumer health space. Each of the three tech titans presented its own unique offering for consumers to store, share, and otherwise manage health-related data about themselves, using a combination of built and partnered hardware and software.

With a macro shift in care delivery away from episodic visits towards data-driven population health management, the health care industry is increasingly interested in a go-to solution that will get patients more directly involved in managing their own health. While the dust has not fully settled, it has become clearer in the wake of initial fervor that these new platforms have a substantial set of challenges ahead of them. In this month’s Domain Monitor, Chilmark Research outlines these challenges and extrapolates their implications for the rest of the industry.

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No Longer Just Chips at Intel

Late last week, Intel announced that it had received FDA approval or its consumer/caregiver centric health device, the Intel Health Guide.

The Health Guide is a single purpose platform to facilitate telehealth by collecting data from devices (heart rate, weight, glucose, etc.) and securely transmitting the data for remote monitoring by a clinician or other caregiver. Intel also states that the Health Guide will also enable secure email communication and delivery of health-related content to the end user (consumer). This is the second product to come out of Intel’s Digital Health Group, the first being a clinician-centric, mobile computing platform, the MCA.

The release of Health Guide follows last month’s announcement by Intel of the social caregiver’s website, ConnectingforCare, which was formed in partnership with the National Family Caregivers Association. This site is still very immature and lacking critical content thus begging the question – Do we really need another social community website such as this when we are already inundated with numerous, healthcare centric social sites?

Reading through some of Intel’s documents (caution PDFs) on their health care evolution and design philosophy, it is clear that Intel has every intention to move from a passive player in the market, supplying microprocessors (chips) to any and all takers, to becoming a direct developer, marketer and seller of devices such as the Health Guide. Intel sees a huge opportunity in the telehealth market to serve an aging baby boomer population that will increasingly use technologies such as this to manage their health, in conjunction with their physician, from the comfort of their home.

Savvy move on Intel’s part as there is indeed a significant opportunity and I see no single dominant player in the market today. Sure, Philips is there as well as Omron and Panasonic, along with GE giving it a close look but no one has taken a commanding lead. Thus, there are no formidable barriers to a new entrant such as Intel. It is still a wide open market.

But in reading the announcement I am struck by the lack of reference on Intel’s part as to how the Health Guide fits into the broader context of care and in particular, electronic records, be they PHR, EMR or EHR. No reference whatsoever on this front which has me quite puzzled as Intel is a key partner in the Personal Health System (PHS) Dossia, which Colin Evans, formerly of Intel, is now leading. This raises a number of questions:

  • How will the Health Guide fit into a consumer’s existing PHR such as one from RelayHealth which already has secure physician-consumer communication embedded in the PHR?
  • Similarly, how will Health Guide interface to a solution like ICW’s LifeSensor PHR that has a significant number of interfaces to existing biometric devices?
  • How might Health Guide integrate into a clinician’s existing workflow and EMR solution and if the clinician offers a patient portal, will Health Guide automatically populate the patient portal with biometric data and any communications that occur electronically?
  • What might be the connection between the Health Guide and a PHS. For example, Microsoft’s HealthVault is in many ways similar to Health Guide (at least from a software perspective) in that it offers secure communication of biometric data to a secure server for storage and retrieval? Are these competing solutions or complimentary?

In making the announcement of FDA approval, Intel also stated that the product would not be released to market until late this year or early next. That should give Intel enough time to further clarify the positioning of Health Guide and address the questions above. Otherwise, despite all the bells & whistles, Health Guide will struggle.

For a more positive spin on the Health Guide, here’s a brief interview with the Health Group WW Director of Marketing and Sales.


Snap Shots from HIMSS

Here at the big, dare I say massive, healthcare IT (HIT) conference for the next couple of days. It is late, I’m exhausted, and the prose may not be the best, but wanted to give a few impressions/snap shots from this first time attendee.

Did I say big? Indeed it is with some 900+ exhibitors this year and those exhibitors range from the big boys, like GE, Siemens and Philips to nano-sized, niche vendors selling odd widgets that not many people seem terribly interested in.

HIMSS is very insular and could use some outside perspective(s). Sessions I attended today had senior IT executives from providers and vendors all parroting themselves. A certain amount of this can be expected, but I find an unusually high level of it here.

The dominant view is that it is not a consumer, but a patient that everyone is ultimately serving. While I understand and appreciate where this perspective originated from, it is a perspective that is so 80’s. The times they are a changing and the CIO needs to begin looking outward to engage the consumer. I’m not seeing any originality here at HIMSS on how to make that happen. Too bad Deloitte isn’t here to give a keynote presentation on some of the findings from their recent consumer healthcare study, that might shake them up a bit.

Then again, maybe not.

A couple of CIOs I spoke with told me that they get very little consumer traffic on their hospital’s website and what little consumer traffic they do get is 80%+ focused on the job listings. Therefore, they are dedicating resources to other, more pressing activities.

With all the buzz about consumer health and a consumer’s purported desire to use Web-based tools (see recent Deloitte report), makes one wonder where is the disconnect. Is it just that these CIOs have made their websites so difficult to navigate that a consumer simply gives up, or is it just easy for someone being interviewed over the phone to say yes, sure I’d like to schedule an appointment over the Web with my physician, but when giving that capability, still reverts back to traditional methods. This is something that is going to require more digging to get to the bottom of.

Sat through a somewhat embarrassing media session hosted by HIMSS to present the findings of their annual CIO Leadership survey. Embarrassing for one savvy reporter pointed out some serious inconsistencies in the survey data exposing some equally serious flaws in methodology. And what I found particularly bizarre is what the survey left out. For example, no inquiry on pay for performance, even though this is a key business issue that will be heavily dependent on HIT in the future.

The most grandiose, over the top booth award goes to McKesson, who has a huge exhibit with the biggest light display I have ever seen at any conference. They certainly blew out their carbon footprint with that exhibit. Sure hope they don’t have any “Green” messaging in their booth.

The most understated booth award goes to our most recent entrant to the HIT market, Google, who had at best a 10’x20′ booth which was absolutely abuzz with people 4-5 deep, which basically crowded out the aisle as well. Luckily, I know one of the Google Product Managers and was able to get in quickly, get some questions answered and move on. Google is still very sensitive about their PHR, quickly shooing someone away when they tried to grab a quick pix with their cellphone.

The most effective booth display was EMR vendor Epic’s posting of their most recent KLAS rankings. Needless to say, they are blowing away their major competitors, Cerner, Eclipsys, McKesson, Siemens and GE. Simply amazing how far ahead Epic is ranked on a variety of key metrics in comparison to these competitors.

Best demo: RelayHealth PHR. I knew RealyHealth did consumer-physician communications, but I did not know that they had as much PHR capability as they demonstrated to me today. Really quite something, though I have some reservations about the solution as it is really targeted for the physician and actual patient control features appear to be weak. Will learn more tomorrow when I sit down with one of their executives.

At this point, I’ve been going for 17+ hours straight. Time to get some sleep and get ready for another long day tomorrow.

Note: For some reasons, quite possibly due to exhaustion, inadvertently hit the wrong button so this did not go up last night as planned. So, slightly late but still relevant.

Predictions 2008: Telehealth Jumps, RHIOs Fade, Legislation Stalls & PHRs Get the Press

A common practice in the analyst community is to take a look back at what has occurred and project forward as to what we might see in the coming year. I won’t spend anytime on what has occurred as you can always drift back to previous posts.

Following are the Top Ten predictions for 2008. Note, these predictions are primarily focused on our core research competency – Personal Healthcare Technology. And if these top ten differ from yours, by all means give us a comment providing your list.

1.) Election Year Puts Many Initiatives in Neutral
2.) Telehealth Continues to Gain Momentum Driving Consolidation
3.) Consumer Electronic Manufacturers Jump on Telehealth Bandwagon
4.) Legacy HIT Vendors Copycat AthenaHealth with Their Own SaaS Offerings
5.) PHRs Still in Headlines, While Adoption Stumbles Along
6.) Attention Turns to PHSs, but Vision Remains Well Ahead of Reality
7.) PDF – Healthcare Hits the Streets, Retail Clinics Love it, Physicians Less So
8.) Personal Identifier Initiatives on the Hill are DOA in ‘08
9.) Employers Expand High Deductible Plan Offerings, Consumers Challenged
10.) HIEs Hold Steady, RHIOs Fade Away – Major Re-thinking of NHIN

Election Year Puts Many Initiatives in Neutral
As the Bush administration continues to see high-ranking officials leave office, no new healthcare-centric initiatives are launched and those, such as the ill-fated National Health Information Network (NHIN), are put on life-support. Even pay for performance (P4P) activities are pulled back until a new administration is in place (mid 2009).

Telehealth Continues to Gain Momentum Driving Consolidation
2007 saw several reports touting the efficacy of telehealth practices, from interacting with a physician over the Internet to the migration of outpatient care and monitoring to the home via health sensor networks and the Web. This will be one of the strongest areas of growth in healthcare technology in 2008 with annual percentage rate growth in the mid-teens. Growth will drive consolidation, as large established players such as Philips, GE and Siemens acquire smaller device manufacturers with either unique technology platforms or specific vertical market presence.

Consumer Electronic Manufacturers Jump on Telehealth Bandwagon
The growth in telehealth and simple demographics (this market will only get bigger) will attract other electronic manufacturers with strong Brand and established consumer distribution channels. Think Sony, Toshiba, LG. Still too early for Nokia and Apple, but they are coming. These companies will also look to acquire, or partner with established players in the personal health technology market to gain domain knowledge and market presence. The upcoming CES confab in Las Vegas may shed some light on who will make the first move.

Legacy HIT Vendors Copycat AthenaHealth with Their Own SaaS Offerings
The success of AthenaHealth in the market and on Wall Street (10th best performing IPO in 2007) is certainly not lost on the traditional Healthcare IT (HIT) vendors. Like the software firms in the enterprise market who have all tried to replicate with their own SaaS CRM solution, expect the legacy HIT vendors to do the same in their attempts to replicate AthenaHealth. Expect the same lack of success. To date, none of the traditional enterprise software vendors have been able to catch, which still shows remarkable momentum in the market.

PHRs Still in Headlines, While Adoption Stumbles Along
With the impending release of Google Health in the first half of 2008, we will continue to see a lot of press dedicated to Personal Health Records (PHRs). Despite the press and employers who continue to adopt these solutions for their employees to foster better healthcare practices, there remain many significant challenges that will prevent the PHR market from really breaking out. Expect 2008 to be a build-out year for PHR vendors, thus tracking large customer wins, partnerships and alliances of these vendors will be critical to assess long-term viablity.

Attention Turns to PHSs, but Vision Remains Well Ahead of Reality
Microsoft has HealthVault, employers have Dossia and Google will have Google Health (or some other Brand name) by mid-2008. All of these are Personal Health Systems (PHSs). They are not a PHR, but a data repository and ultimately a utility that other applications, including PHRs can tap to serve the consumer. Each of these PHSs have enormous resources behind them, but their vision is far ahead of what they will be able to deliver in 2008. There is a lot of heavy lifting (standards, tagging, document management, security, etc.) that these entities will need to address, consuming most of 2008. Look to mid-2009 for these systems to be at a level of functionality that is useful to the broad market.

PDF-Healthcare Hits the Streets, Retail Clinics Love it, Physicians Less So
The “Best Practices Guide” for the use of PDF-Healthcare is making its way through the formal review process with expected release in the next month or so. Currently being used by one of the largest retail clinics, PDF-Healthcare has demonstrated its utility for this retail clinic that is now exchanging over 10,000 unique PDF-Healthcare documents a day throughout its organization.

While this retail clinic has reaped a number of advantages through the use of PDF-Healthcare, and larger healthcare providers will do so as well, smaller physician practices will be challenged by this format as most are ill equipped to accept such digital documentation. Thus, PDF-Healthcare will become another forcing function for physician adoption of EMR, something that most have been loathed to do.

Personal Identifier Initiatives on the Hill are DOA in ‘08

Several proposals surfaced in 2007 calling for the establishment of a personal identifier for American citizens to better track/tag their medical records. This is becoming increasingly relevant as use of digital records accelerates. Despite a very real need for personal identifiers, this issue exacerbates existing fears of privacy and government intrusion. Thus, this will not see the legislative light of day in 2008. A new administration may take it up in 2009 if they receive a strong mandate from the public (i.e., a landslide victory).

Employers Expand High Deductible Plan Offerings, Consumers Challenged
Building upon the growing trend we saw in 2007 of employers seeking new ways to lower their exposure to double digit growth in medical benefit costs, consumer-driven health plans, most often with high deductibles, are now in vogue. Young, healthy employees sign-on to such plans, chronic care sufferers reject them and middle-age employees with families struggle to determine what is best for them. Unfortunately, for this latter group few resources are available to assist them with making the best choice. And as for those young, healthy and very often Internet-savvy employees, they look to the Web to help them pick a doctor and control expenses. But they to will come up empty handed as cost transparency will remain elusive in 2008.

HIEs Hold Steady, RHIOs Fade Away – Major Re-thinking of NHIN
The reports released at the end of 2007, the first on the relatively dismal state of Regional Health Information Organizations (RHIOs) and the second on the modest success of Health Information Exchanges (HIEs) were simply a harbinger for 2008. Expect 2008 to deliver more of the same for RHIOs as they continue to struggle to establish a value proposition that will overcome competing entities participation in a RHIO. And there is the nagging issue of a revenue model for RHIOs to make them self-sustaining long-term – to date, this issue has not been solved. Both of these problems will lead to nearly a third of the remaining RHIOs closing their doors by the end of 2008 and another third will be best characterized as the walking dead.

While RHIOs fade, HIEs will continue to operate and see modest growth. Unlike RHIOs, HIEs are formed by entities that have a strong desire to share information, not withhold it. But HIEs will not be the panacea to the need for a NHIN as their reach will be limited and highly localized. This will limit the overall growth of HIEs and subsequently, their impact to the market.